Re-Imagining Healthcare in the 21st Century

Merav Dover, Chief Officer of Southwark and Lambeth Integrated Care (SLIC), has worked in the NHS and central government for over 20 years. She describes being able to redesign care across organisations, radically transforming care to improve people’s lives, as ‘a gift’.

Here Merav talks to us about SLIC and how re-imagining 21st Century care requires extraordinary commitment, skills and resilience…

What does Integrated Care mean to you?

In Southwark and Lambeth it’s about radically redesigning how care is provided, breaking down silos and making the best use of our money and our people – clinicians, professionals, carers and citizens – by supporting them to work together to help local people live healthier and happier lives.

It’s also about supporting people to take control of their care. The current system is designed for people to be dependent recipients of care, but local people told us they wanted to be in control of their own health and wellbeing, and integrated care is about supporting them to do that.

Why is a holistic approach so important?

A holistic approach means looking at a person in the round, not as a set of conditions, taking into account their social, mental and physical care needs. Holistic Assessments allow people to talk with their GP about their concerns, wants and needs and develop with them a comprehensive care plan to address these. [In one case], a lady was visiting her GP surgery every day, waiting for it to open each morning. Through a Holistic Assessment her GP found out that her medical condition was less important to her than the fact that she had been very lonely since her mother had died and that she wanted to have a reason to leave the house. An Age UK Care Navigator, working in partnership with the practice, helped her gain confidence and took her to an arts and crafts class, which she still continues to attend. She’s made friends and now only visits her GP when she has a medical reason to do so.

What has made SLIC so successful?

It’s not just what we’ve done – it’s how we’ve done it. The ‘what’ to some extent was fairly obvious. For example, older people told us they wanted more transparency and communication between their GPs and hospitals to avoid having to explain their history at each appointment. In response, we implemented a system whereby every GP and every clinician within each of our three hospitals can see each other’s records in real time. We call it a ‘Local Care Record’.

The ‘how’ wasn’t quite as straightforward. When SLIC began in 2012 we didn’t know precisely how to do things, as we were testing. We knew, for example, that we wanted to do a falls prevention project but we didn’t know precisely how it was going to work. We succeeded because we realised we needed to focus on getting the basics in place – for example, we involved a range of stakeholders in co-designing a programme, and used quality improvement methodology to review its success.

Ours is a story of learning, honesty and self-challenge and I think it’s this which really brought about our success. We learned and adapted as we went along and it was having the courage to say ‘this isn’t working’ and then try again that allowed us to eventually get it right.

What can other organisations learn from this programme? And will we see this across the country?

Integrated care is now a well-used term – it’s a key part of the NHS Five Year Forward View, the focus of a number of Vanguard Programmes, and every local area has had to form Sustainability and Transformation Plans, which include integrating care, so it is certainly happening all over the country. However, I think we were, and probably still are, ahead of the curve in terms of our results because we started earlier and now have a good understanding of what it takes to integrate care, along with committed and talented staff, and strong leadership.

We are very keen for others to learn from our experience – both what we did right, and what we did wrong – and have developed a SLIC Framework for Success to share our learning.

What have been the challenges and successes of SLIC?

At times it is hard. There is always pressure to demonstrate success immediately, so even when you have groups of people working together successfully to redesign care, until you can really demonstrate that it is having an impact on experience, costs and population outcomes, you are met with a degree of negativity and people wanting quicker results than you can necessarily deliver. You’re also asking people who don’t really know each other to work as a team, so we had to build trust and relationships from scratch. And, of course, all this is against a backdrop of steep cuts, so the environment can be very difficult. Despite this, we have had success over the four years of SLIC, and 24 of the 27 interventions that we have tried and tested are now mainstreamed, or undergoing continued testing. We have also stabilised emergency admission and bed days for older people, and have massively reduced the number going into nursing and care homes – and all within the context of a local 5% population increase in people aged over 65.

What does the second phase of the SLIC Partnership look like? What do we have to look forward to?

While the four-year SLIC programme ended in March 2016, the partnership is continuing. As the Southwark and Lambeth Strategic Partnership they will build on the successes of SLIC to continue to improve care for even more local people. They have begun working on a big transformation programme for children’s and young people’s services, and there is a commitment to do a big piece of work on data, as we need to understand our population in order to be able to respond to their needs. At the moment, every organisation is holding a little bit of data and we need to pull all that together so we have a more complete picture. These are just some of the broad priorities of the partnership going forward – there is zero complacency and 100% commitment to continue with the good work that SLIC started.

Other than looking at children’s needs and over 65s are there any specific areas of healthcare that you would like to see more integrated or ‘at home’ as opposed to in a hospital?

I think it is about providing care in the most appropriate place. Sometimes that is in hospital, but there are other places as well, for example in your own home or in residential care that can become your own home. We need to think about which place is most appropriate so that people can really flourish. Helping people get home earlier from hospital so they don’t lose their independence is really important. In many cases people don’t need any more nursing or medical attention per se, but we are not really sure whether they can manage at home. In hospital things tend to be done for you, so it is not necessarily the best place to assess whether you can be independent or not. SLIC created Extra Care accommodation– flats that are made to feel like home – where people could do as much for themselves as possible like taking their own medicine, making a cup of tea, answering the doorbell, getting dressed, going to the toilet on their own, while being closely monitored. This also meant a comprehensive assessment of their needs could be carried out in a home-like environment and that they were able to recover in a safe environment before returning to their own homes.

People tell us they want to be at home whenever it is appropriate to be at home, so it’s important to focus on prevention too. When it looks like people are getting to the stage where hospital admission may be likely at some point, we have an Enhanced Rapid Response team made up of social care, therapists and nurses, who are able to provide care in the home.

Finally, it is obvious that you are very passionate about what you do – you have to be to overcome all the challenges and stay motivated – but what is it that makes you passionate about integrated care, what draws you to that area?

There are two things for me. Firstly, I love seeing first-hand the profound difference it makes to local people’s lives. Secondly, it’s the huge difference it makes to professionals’ lives. We have superb social care workers, doctors, nurses, managers and leaders and seeing how working differently improves their working lives is incredibly motivating.